Asthma and pregnancy

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incidence and prevalence of asthma in pregnancy, guidelines for diagnosis and management of during pregnancy. drugs to be given and drugs to be avoided during pregnancy. pregnancy outcome in asthma patients.

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Asthma and pregnancy

  1. 1. ASTHMA AND PREGNANCY
  2. 2. Dr S. RAGHU M.D., ASSOCIATE PROF Department of TB & CD Guntur medical college & Chest physician Govt fever hospital Guntur
  3. 3. Lungs in pregnancy Lung volume changes associated with pregnancy:  Decreases : FRC(10-25%) ERV(8-40%) RV(7-22%)  Increases : IC  No change : TLC VC
  4. 4.  Tidal volume increases considerably, i.e. 30 to 35%, as a result of increased ventilatory drive.  Minute ventilation increases 20 to 50 percent before the end of the first trimester due to an increase in respiratory drive.  Due to effect of increased serum progesterone-a direct respiratory stimulant(from 25 ng/ml at 6 weeks to 150 ng/ml at 37 weeks)  Therefore tachypnea during pregnancy is an important abnormal finding that must be investigated
  5. 5.  Increase in Minute ventilation causes HYPERVENTILATORY PICTURE as a normal state of affairs in the later half of pregnancy. 1. chronic respiratory alkalosis 2. partial pressure of CO2 (PCO2)  ( 28-32 mmHg) 3. bicarbonate (HCO3-)  ( 18-21 mEq/L)) 4. pH . ( 7.40-7.45) 5. PO2  > 100 mmHg  A normal pCO2 in a pregnant patient may signal impending respiratory failure.
  6. 6. Statistics of asthma in pregnancy  Prevalence of asthma in pregnancy: 4-8%  52% of severe asthmatics prone to Exacerbations during pregnancy  55% of asthmatics have atleast One exacerbation during pregnancy  20% have a severe exacerbation during pregnancy requiring medical intervention.  5.8% of pregnant asthmatics are hospitalized for a severe exacerbation.
  7. 7.  A 20 yr old lady presented with  Hx of cough and dyspnea for 6 months  2 weeks of drug discontinuation  1 week cough, sputum and dyspnea  She is 3 mo pregnant  She is concerned about her chest disease during pregnancy
  8. 8.  Is it really asthma?  Why me? I had no family history.  Does pregnancy cause my asthma to be exacerbated?  Can my asthma be cured?  Can moisturizers help me to improve?  How does asthma affect my fetus?  Are asthma drugs risky for my fetus?  Is my child more prone to asthma?  Can heartburn cause my asthma?  Should I get flu shot?  What should I do in the case of asthma attack?
  9. 9. Effect of pregnancy on asthma  1/3 better (23%)  1/3 no change  1/3 worse (30%)  Women with severe asthma tend to have worsening of their asthma.  Asthma exacerbations can occur at any time during gestation but tend to cluster between 17 & 34 wk gestation.(mean 25 wk)  Effect of pregnancy on asthma tends to be similar in successive pregnancies
  10. 10.  Risk factors for asthma AE: -respiratory viral infections -discontinuation of treatment due fears about their safety
  11. 11.  Hyperemia, friability, mucosal edema, and hypersecretion of the airway mucosa occur throughout pregnancy.  These changes are most pronounced in the upper airways, especially during the third trimester.  Hense the asthmatics are prone to RTIs during pregnancy and also have an increased risk of CAP.
  12. 12.  Asthmatic women who smoked during pregnancy  multiple severe exacerbations.  Other factors that may worsen asthma during pregnancy : psychological stress, GERD, allergic rhinitis.
  13. 13. Effect of asthma on pregnancy  Maternal health risks Hyperemesis gravidarum preeclampsia gestational hypertension uterine haemorrhage placenta previa maternal morbidity & mortality
  14. 14.  Fetal health risks neonatal hypoxia low birth weight preterm birth small for gestational age(IUGR) congenital anomalies ( eg; cleft palate especially with triamcinolone) perinatal morbidity & mortality
  15. 15.  Poor controlled asthma has been associated with 15 to 20 % increase in both maternal & fetal risks  These risks are increased 30 to 100 % those with more severe asthma.  Asthma is not associated with risk of congenital malformations
  16. 16. D/D for acute respiratory distress in pregnancy  Venous thromboembolism  Amniotic fluid embolism  Pulmonary edema secondary to preeclampsia  Tocolytic pulmonary edema  Aspiration pneumonitis  Peripartum cardiomyopathy  Pneumomediastinum  Air embolism  Other: asthma, pneumonia, cardiac disease, ARDS
  17. 17. Asthma & Pregnancy management Goals:  Control symptoms, including nocturnal symptoms  Prevent acute exacerbations  No limitations on activities  Maintain (near) normal pulmonary function  Minimal use short-acting inhaled beta2- agonists  Protect the mother and fetus from
  18. 18. To achieve goals  Maternal lung function monitoring  Symptoms  Spirometry  Peak flows  Fetal monitoring  Ultrasound monitoring  Elektronic fetal hearts
  19. 19. General Principles  Preconception; − Optimize asthma management. − Few changes in treatment regimen are needed in pregnancy especially if asthma is controlled.  Avoid recently introduced medications whose safety in pregnancy is not established.  Use adequate doses of medications to control symptoms and avoid hypoxia.  It is essential to maintain adequate oxygenation to the fetus.
  20. 20. Components of Asthma Management  Objective measures for assessment and monitoring  Patient education  Avoidance of factors contributing to asthma severity  Pharmacologic therapy-  Diagnose and treat rhinitis, sinusitis or gastroesophageal reflux disease if present
  21. 21. Environmental Control in Asthma eliminate these “mobile allergen bearing units” & quit smoking
  22. 22. Drug treatment of asthma in pregnancy
  23. 23.  As asthma is an inflammatory disease limited to lung airways, the drug treatment of asthma in pregnancy is similar to the treatment of asthma in non- pregnant women.  Treatment of this disease in a topical form is  More effective  Less harmful
  24. 24. Medication safety in pregnancy  FDA Pregnancy Risk Classification for Drugs:  Category A No risk demonstrated in 1st trimester in controlled studies in women, no risk in later trimesters  Category B No risk in animal studies, but controlled studies in women not done  Category C Fetal harm in animals, no studies in women (or studies in animals & women not available)  Category D Evidence of human fetal risk, but benefits > risk in life-threatening situations  Category X Contraindicated in pregnant women
  25. 25. drug FDA category BUDESONIDE B CROMOLYN B NEDOCROMIL B MONTELEUKAST B ZAFIRLEUKAST B TERBUTALINE B IPRATROPIUM B BECLOMETHASONE C FLUTICASONE C ALBUTEROL C THEOPHYLLINE C SALMETEROL C FORMOTEROL C
  26. 26. Potential Adverse Effects of Common Asthma Drugs on the Fetus Drug class Effect on fetus Theophylline incresed HR, vomiting, jitteriness (mother/fetus) when maternal levels > 12 mcg/mL Systemic b2 Agonists incresed fetal HR & neonatal HR, tremor, Hypoglycemia LT modifiers not known, animal data - teratogenecity of zileuton Decongestants Uterine vasoconstriction, fetal gastroschisis Corticosteroids preeclampsia, preterm and low birth weight, cleft palate 1st trimester (incidence 0.3%)
  27. 27. Medications to be Discouraged in Pregnancy  Frequent injections epinephrine (category C)  Oral decongestants in the first trimester  Iodine-containing cough medications  Tetracycline (category D)  Aspirin and NSAID (category D)  Beta-blockers  Prostaglandins
  28. 28. Stepwise Approach for the Management of Asthma During Pregnancy
  29. 29. Step 1 – Mild Intermittent Asthma Clinical Presentation  Intermittent symptoms  Brief exacerbations  Normal between exacerbations  Nighttime symptoms < 2/month  PEF or FEV1 is: > 80% predicted Controller : No daily medication needed Quick Relief : Inhaled b2 -agonist (salbutamol)
  30. 30. Step 2 – Mild Persistent Asthma Clinical Presentation  Symptoms > 2x/wk  Nighttime symptoms > 2x/month  PEF or FEV1 is:> 80% predicted Controller : Low dose inhaled steroid (Budesonide) Cromolyn, leukotriene receptor antagonist or theophylline Quick Relief Inhaled b2-agonist (salbutamol)
  31. 31. Step 3 – Moderate Persistent Asthma Clinical Presentation  Daily symptoms  Daily use of b2-agonist  Nighttime symptoms > 1x/wk  PEF or FEV1 is: 60 – 80% predicted Controller: Inhaled steroid + long-acting b2-agonist (or) Increase dose inhaled steroid Alt: ICS + Leukotriene receptor antagonist or theophylline Quick Relief: Inhaled b2-agonist
  32. 32. Step 4 – Severe Persistent Asthma Clinical Presentation  Daily symptoms  Frequent nocturnal awakenings  Frequent exacerbations  PEF or FEV1 is: ≤ 60% predicted Controller : Inhaled steroid (high-dose) Long acting b2-agonist and if needed Oral steroids Quick Reliever Inhaled steroid (high-dose) Long acting b2-agonist and if needed Oral steroids Short acting inhaled b2-agonists
  33. 33. Management of Acute Asthma in Pregnant Women  Oxygen supplementation (SaO2>95% / Po2 >70)  İntravenous fluid hydration (if necessary)  Inhale salbutamol (every 20 mins up to three doses in the first hour)  Ipratropium bromide (500μg) (in severe cases)  Systemic corticostreoids either intravenously or orally (in moderate/severe cases)  Dosage of glucocorticoids is not different  IV aminophylline NOT generally recommended  IV Mg sulfate may be beneficial
  34. 34. What is “well control” ?  No (or minimal) daytime symptoms  No limitations of activity  No nocturnal symptoms  No (or minimal) need for rescue medication  Normal lung function  No exacerbations
  35. 35.  In pregnant asthmatics you should confirm control by  Spirometry  Monthly  Peak flow metry  Twice daily Upon awakening & After 12 hr
  36. 36.  FEV1 < 80% in pregnancy associated with poor pregnancy outcomes  Moderate to severe asthmatics  Serial ultrasound examination of fetus -Early in pregnancy -Regularly after 32 wk -After an asthma exacerbation
  37. 37. Immunotherapy During Pregnancy  No advers effects on pregnancy outcomes  Anapylaxix may a risk for mother and baby Recommendations  Do not begin immunotherapy during pregnancy  Carefully continue ongoing effective immunotherapy (avoid systemic reactions)
  38. 38. Flu shot  Influenza vaccination is necessary for:  Pregnant women with 2nd and 3rd trimester  In cold months
  39. 39. Obstetrical Management of Pregnants With Asthma In case of cesarian section:  Lumbar epidural analgesia (Decreses O2 consumption and minute ventilation)  Fentanyl (as a narcotic analgesic)  If general anesthesia required -Ketamine is preferred In case of labour:  Oxytocin and prostaglandin E2 suppositories (for labor induction)  Pitocin, misoprostol (for postportum hemorrhage)
  40. 40. Obstetrical management Should be avoided  Morphine  Meperidine  15-methylprostaglandin F2α  Ergot alkaloides  Whole delivery team should be made aware of existing asthma, particularly anesthetist.
  41. 41. Asthma and Lactation  There is no effect of lactation on maternal asthma.  Prednisone, theophylline, antihistamines, ICS, SABAs, LABAs and cromolyn are not contra-indicated.  Theophylline may cause neonatal irritability, feeding difficulties.
  42. 42. Allergic Rhinitis and Pregnacy Intermitten rhinitis (symtoms less than 4 days a week or for less than 4 consecutive weeks ) − Mild: • Loratadine or cetirizine as needed − Modarate- severe (İmpairmen of sleep, daily activities, school or work or trouble some symptoms): • Intermitten intrasal budesonide, supplemented by loratadine or cetirizine as needed
  43. 43. Allergic Rhinitis & Pregnacy Persistent Rhinitis (symptoms more than 4 days per week and for more than 4 consecutive weeks)  Mild:  Intranasal cromolyn supplemented by loratadine or cetirizine as needed  Moderate-Severe:  Regular intranasal budesonide, supplemented by loratadine or cetirizine as needed; immunotherapy
  44. 44. Take home  The biggest danger is poorly controlled or under- treated asthma.  Avoid exposure to tobacco smoke and other irritants.  The treatment is similar.  Maintenance rather than symptomatic therapy  No studies have related ICS to an increased risk for the fetus.  Preferred controller: Budesonide [Category B]  Aggressive treatment of exacerbations  It is unusual for asthma to cause problems in labour.
  45. 45. Thank you..

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